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This Concept Map, created with IHMC CmapTools, has information related to: pressure ulcers, Pressure Ulcers classification Stage IV- full thickness skin loss, with extensive tissue damage. Extends through muscle, tendon &/or bone, extends through fat into other tissue, Pressure Ulcers classification Suspected Deep Tissue Injury- must have the following characteristics: blood blister, discolored intact skin, pain, boggy., Pressure Ulcers classification Stage I Non blanchable erythema (non reactive hyperemia) intact skin, red, non-blanchable, Pressure Ulcers 3 factors Intensity, Duration, Tissue Tolerance, Intensity, Duration, Tissue Tolerance other contributing factors Altered sensory perception, Alterations in LOC, impaired mobility, Shearing, friction, moisture., nutrition, tissue perfusion, infection, obesity, advanced age., Pressure Ulcers classification Unstageable-Must be debrided to see full extent of tissue loss. (unless heel). Has eschar or slough., Pressure Ulcers classification Stage III- full-thickness. involves sub-q tissue. May have undermining & slough., Pressure Ulcers classification Stage II-partial thickness skin loss. Only pinkish- no yellow(fat), white (bone) or red (muscle), Altered sensory perception, Alterations in LOC, impaired mobility, Shearing, friction, moisture., nutrition, tissue perfusion, infection, obesity, advanced age. drugs that contribute anti-inflammatory (steroids, nsaids, aspirin) antibiotics, chemotherapy (dec. WBC), anticoagulants